HomeMy WebLinkAboutVeterans_HartleyForm Number 12 - Revised 1977
Prescribed by State Board of Tax Commissioners
.. VETERANS, OR THEIR WIDOWS, STATEMENT OF TOTAL DISABILITY
� and Application for Deduction From the
Assessed Valuation of Taxable Property
*** Qualifications on Back **•
/ / �
STATE OF INDIANA /;'/� COUNTY ,
(Name) , being duly sworn on oath says
that (s)he is e • that (s)he resides at ��.�'7�
��{�'� . �y� County, Indiana; that (s)he
Check One:
was a nurse
was a Member of the U.S. Armed Forces
or the widow of a member of the U.S. Armed Forces
and who served for ninety (90) days or more, not necessarily during the
time of war, and has been honorably discharged therefrom and has a total
disability and is entitled to this dedu.ct.iqn�as evidenced by:
I',� � � � �..�
Pension Certificate or ,��-
Award of �Compensation or
� Veterans Administration Form 20-5455 '�T�� 2Hb'a�t�ement Certificate" or
Letter statement of Total Disabliity from the Department of the
Defense �,
Disability Retirement Board or the-appro.priate branch of the
armed forces r''�TO�R ���,
�� :�hibited to the County:Auditor. ,
IC 6-1. 1-12-14 and 6-1. 1-12-15
That this application is made for the purpose of obtaining $� oB �
(not to exceed one thousand dollars) deduction from the assessed valua-
tion of the following described taxable property for the year 19�/, to
wit: -�"� �
TAXING DISTRICT (CITY, TOWN,�� �,c.a-w_.y �..L-�w�
� �
LEGAL DESCRIPTION OR KEY NUMBER
That, in addition to the above amount of $ deduction applied
for in this County, (s)he has or intends to apply for $ deduction
�
in County, Taxing District and that
the total assessed value of all his/her taxable property as shown by the,
.�
S
tax duplicates of all counties in which they own property is S
x �1�-o-�c- ,Q %
�} (Appl ca /Guardian)
I
� Subscribed and sworn to before me, and disability verified this
�� day of , 19l��. �� /o ,�
�Ji�bc.�-�
' Auditor